Page 10 - Optima Tax EE Guide 01-20 CA w Kaiser

Medical Plan Highlights

Kaiser Anthem
Plan Name HMO Basic PPO
Network Name Kaiser of CA Prudent Buyer Non-Network*

Plan Differences
Employee Premiums $$$ $
Employee Cost Sharing Contribution, Copay Contribution, Deductible,
Copay, Coinsurance
Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits ✓

Access to Providers Managed by Your PCP Managed by You
Health Benefits
Lifetime Max Benefit Unlimited Unlimited
Deductible (Cal Year)
- Individual $0 $1,500
- Family $0 $3,000
Out-of-Pocket Maximum
- Individual $3,000 $6,000 $12,000**
- Family $6,000 $12,000 $24,000**
Coinsurance (Plan Pays) 100% 80% 50% *
Office Visit Copay
- Preventive Care No Charge No Charge Not Covered
- PCP $30 Copay $30 Copay Deductible, 50%
- Specialist $50 Copay $40 Copay Deductible, 50%
- Urgent Care $30 Copay $30 Copay Deductible, 50%
- Retail Clinic n/a $15 Copay Deductible, 50%
- Virtual Visits: LiveHealth Online No Charge $5 Copay N/A

24/7 Nurseline No Charge No Charge N/A
Hospitalization
- Inpatient $500/day to OOP Max Deductible, 20% Deductible, 50%***
- Outpatient Surgery $250 Copay Deductible, 20% Deductible, 50%***
Lab and X-Ray
- Diagnostic $10 Deductible, 20% Deductible, 50%***
- Radiological/Nuclear $100 Deductible, 20% Deductible, 50%***
Emergency Room Services $100 Copay 20%
Chiropractic Not covered $40 Copay Deductible, 50%
Max 20 Visits/Year

Acupuncture Not Covered $40 Copay Deductible, 50%
Max 20 Visits/Year
*Out of network providers are reimbursed by our plan at Anthem Fee Schedule .

**The out-of-pocket max, is the most you may pay in a year for covered services. Premiums, balance-billing charges,
health care this plan doesn’t cover & penalties for failure to obtain pre-authorization for services is NOT included in the
out-of-pocket limit.

*** Additional coverage maximums apply to Non-Network providers. Please refer to plan documents for more details.

10 Employee Benefits